The doctor dilemma

WINNIPEG — When the NDP made its bold pledge of a doctor for all, the day of reckoning seemed a long way off.

Now, with the Selinger government more than halfway into its mandate, the Free Press decided to examine how well the NDP is doing in delivering this key health care promise — and whether it is, in fact, achievable.

Roughly 14 per cent of Manitobans age 12 and older — or about 145,000 residents — lacked a family physician when the pledge was made, Statistics Canada says. Of those, surveys indicate, likely half weren’t looking for one — meaning there were 70,000 to 75,000 Manitobans searching for a doctor at the time.

How is the province doing so far? The most recent stats aren’t very current — and also not that encouraging. By the summer of 2012, Statistics Canada pegged the percentage of Manitobans without a family doctor at 15.6 per cent — higher than the previous year and around the average for the past decade.

The numbers have been “flat,” Manitoba Health Minister Erin Selby admitted in a recent interview.

But she said the government has set several initiatives in motion that, it hopes, will soon bear fruit.

Selby also amended the government’s original promise. “Our benchmark is going to be — can you get connected within 30 days with a family doctor if you want one,” she said. “That’s what we’re going to measure ourselves up against.”

How many do we need?

How many family doctors do we need before everyone who wants one has access to one?

Is it a question of numbers? Or does the health system need to find a better way to use them?

How can the system change to meet the needs of the future when family physicians are still by and large established as entrepreneurs, working in silos, earning their living in what some feel is an antiquated fee-for-service model?

Those are all questions governments and health policy gurus have been wrestling with for years.

So, how many family doctors do we need?

“It’s an absolutely impossible question to answer,” said Dr. Alan Katz, associate director of the Manitoba Centre for Health Policy, who has examined the issue.

That’s because there are so many variables, Katz says. Some would say a family physician can serve 1,000 patients. Others would say an experienced, workaholic MD could look after as many as 1,800.

But these numbers depend on such factors as the age of the population being served and how many patients in a given medical practice suffer from chronic illnesses that require more physician visits.

“If the population is highly skewed towards people between the ages of 25 and 45, like Alberta’s for instance, they may need fewer doctors because these people are generally healthy,” Katz said. “If your population is older, then you need more doctors.”

Changing demographics and evolving medical and patient practices can also have a profound impact on medical specialties. For instance, an aging population creates a greater demand for orthopedic surgeons.

Changes in the health and care of children are reducing the demand for pediatricians and some family physician services. “We know that kids are actually getting healthier. We also know there was a time 20 years ago when every time a kid had a sore throat they went to a doctor and got an antibiotic. That wasn’t necessary, and it’s not done any more,” Katz said.

Manitoba has about 2,600 licensed physicians, including an array of specialists. About half are family doctors.

Over the past 10 years, the province has added 450 physicians through doctor recruitment and increased enrolments at the University of Manitoba.

Still, tens of thousands of Manitobans — many in remote areas, but also many in Winnipeg — lack a physician of their own.

And with more than one-third of Manitoba physicians over age 55, there will be continued pressure to find enough doctors to meet demand.

Younger physicians are seeking a better work/life balance, so it might mean that as the older generation retires, it might take five family doctors to do what four used to do.

So how do you find a family doctor for everyone? The answer is to make more judicious use of the ones who are already here — and that means changing how primary medical care is delivered to Manitobans.

For the past few years, the government has been touting nurse-practitioner-operated Quick Care clinics to ease the burden on hospital emergency rooms and doctors’ practices. The clinics — four have been introduced with another four in the works — will also help patients link up with a family physician.

The province has also boosted training for physician assistants and even launched the first mobile clinic, which is expected to handle up to 1,000 patients in western Manitoba in the coming year. Two more mobile clinics, staffed by nurses and nurse practitioners and backed by physicians, are planned in the coming years.

The most important change will be the introduction in the coming weeks and months of so-called “primary care networks” across the province. These will be interdisciplinary teams melding fee-for-service physician clinics with government-paid nurses, dietitians, mental health workers and other professionals, depending on community need. The idea is that by working in teams, health care professionals other than doctors can take on some of the patient visits now handled by doctors, freeing them to accept more patients.

Dr. Tamara Buchel, executive director of the Manitoba College of Family Physicians, said without such innovations it will be all but impossible for the government to achieve its goal of a doctor for all.

“The family doctors that are there in the trenches really need to feel confident that it is a collaborative process and a partnership with the (health) region. I think without that there are, for sure, not enough doctors,” she said.

The government might not be able to fulfil its campaign promise in the coming year, no matter how it restates it. But by making the pledge, it has signalled to family doctors their role is going to change, and it has set out a path for achieving its goal that is backed by such groups as the College of Family Physicians of Canada.

Dr. Brian Postl, dean of the University of Manitoba faculty of medicine, said he believes the new generation of family doctors is more open to working in teams with other professionals.

Historically, he said, doctors decided what they wanted to do, and governments picked up the tab. Now, governments throughout the world are introducing new working models that make the best use of physician skills.

“The growing literature is that health care that is delivered by teams of professionals tends to be both safer and more effective than by professionals working in individual silos,” Postl said.

Younger doctors are also more open to abandoning a strict fee-for-service model in exchange for a salary and pension benefits and a more defined job description, he said, making it easier for them to fit into a team approach.

“I think the basic message is that there’s no shortage of work to do and if we can be clever enough to imagine how we pay people so that they get rewarded for hard work ... we can probably extend all of the capacities of the health professions to take care of more people, and frankly, to take better care of them,” Postl said.

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WINNIPEG — When the NDP made its bold pledge of a doctor for all, the day of reckoning seemed a long way off.

Now, with the Selinger government more than halfway into its mandate, the Free Press decided to examine how well the NDP is doing in delivering this key health care promise — and whether it is, in fact, achievable.

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WINNIPEG — When the NDP made its bold pledge of a doctor for all, the day of reckoning seemed a long way off.

Now, with the Selinger government more than halfway into its mandate, the Free Press decided to examine how well the NDP is doing in delivering this key health care promise — and whether it is, in fact, achievable.

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